Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tiffany Heights during CMS and state inspections, most recent first.
Improper Hand Hygiene During Kitchen Food Preparation: Dietary staff were observed using hand sanitizer and then starting food prep and plating tasks without observed handwashing with soap and water. An aide, another aide, and the Dietary Mgr were seen handling food, kitchen items, and surfaces after sanitizer use only, despite the facility policy requiring soap-and-water handwashing before food handling and after contamination-related activities.
A facility failed to ensure residents could access required resident-rights contact information for the State Survey Agency and Ombudsman. A cognitively intact resident who used a wheelchair said he/she did not know how to contact the survey agency or Ombudsman, and observation showed the posted numbers were placed high on a wall in a narrow area with wheelchair access blocked by a chair. In resident council interviews, seven of 14 members did not know how to file a complaint or where to find the Ombudsman information, and staff confirmed residents would need to ask for the numbers.
Two residents did not have hot water in their room bathrooms at the expected temperature, with measured water temperatures below the facility's stated minimum range and family or resident complaints that the water was never hot enough. In addition, a resident who used a wheelchair had repeated difficulty crossing a raised threshold at the room entrance, requiring multiple attempts to enter the room and describing the situation as frustrating.
The facility failed to ensure residents could file grievances in writing, anonymously, and receive written decisions. In group interview, most residents did not know how to submit complaints or where forms were located, and staff were unsure how anonymous grievances worked. One resident with intact cognition reported filing a grievance about an LPN's conduct but said the Administrator never followed up, and a family member for another resident reported complaints about room water, meds, and signed approvals that were not answered in writing.
A facility failed to develop comprehensive person-centered care plans with measurable objectives and timeframes for two residents. One resident’s care plan did not address ordered O2 use despite COPD and other diagnoses, and another resident’s care plan did not address inappropriate sexual behaviors despite TBI and severely impaired cognition. Staff and the administrator acknowledged that both issues should have been included in the care plans.
Medication transcription and eye drop administration errors affected two residents. One resident with dementia had Donepezil discontinued after hospital transfer even though discharge orders said to continue it, and the resident went without the medication for a period of time. Another resident receiving glaucoma eye drops was observed with an LPN touching the eyelids and eyelashes with the dropper tip and applying lacrimal pressure inconsistently, contrary to policy and accepted practice.
Respiratory care was not properly provided for several residents receiving oxygen therapy. Staff failed to date and document oxygen and nebulizer tubing changes for one resident, failed to provide humidification for three residents with oxygen orders or care plans indicating it, and failed to keep oxygen accessories properly stored at the bedside. Residents were observed on oxygen with tubing left exposed and no humidifier bottle attached to the concentrator, and staff interviews confirmed the expected tubing and humidification practices.
The facility failed to hire or designate an RN to serve as the DON on a full-time basis for a census of 38 residents. Survey observations showed charge nurses were present, but no DON was in place. The Administrator stated the facility did not currently have a full-time DON, the prior DON had stepped down, and an RN was scheduled 8 hours a day during daytime hours with a licensed nurse on every shift.
Resident Subjected to Verbal Abuse and Refused Care: An LPN was reported to have yelled at a resident with TBI and severe cognitive impairment, cursed at him/her, and refused to provide care unless the resident changed behavior. Staff and another resident described the resident being left soiled and needing help with cleanup, while interviews also noted vulgar language and repeated concerns about the resident not receiving respectful care.
Failure to Investigate Alleged Verbal Abuse and Withheld Care: An LPN was reported to have yelled at a resident with TBI, used demeaning language about the resident’s behavior, and withheld assistance while the resident remained soiled with fecal material. The allegation was shared with multiple staff, but it was not handled as an abuse grievance or thoroughly investigated, and leadership acknowledged that reporting to the charge nurse was treated as sufficient.
Incomplete Perineal Care for Dependent Residents: Staff did not fully clean the perineal area for two dependent residents who were incontinent and needed assistance with toileting and hygiene. Observations showed CNAs wiped the groin and genital area but did not separate and clean all skin folds or all areas touched by urine or feces. Staff interviews confirmed peri care should include all wet or soiled areas and all genital areas.
Failure to Address Resident Sexual Behaviors in Care Plan: A resident with TBI and severe cognitive impairment repeatedly displayed sexually inappropriate behavior, including genital exposure and masturbation in front of staff, but the care plan lacked specific interventions or alternative coping strategies. Progress notes and staff interviews showed repeated incidents during toileting, showering, and medication passes, and staff described inconsistent responses, discomfort, and refusal or delay in providing care when the resident was incontinent or needed assistance.
The facility failed to correctly submit PBJ direct care staffing data for Q3 2025. The PBJ report showed no 24-hour licensed nursing coverage on several dates, while daily staffing sheets showed licensed nursing coverage was present 24 hours per day. The facility had no policy for reporting direct care staffing information, and the Administrator stated staffing data was entered by the corporate office but should have been filled out correctly.
A resident with an indwelling urinary catheter was observed in a wheelchair with the catheter bag, dignity bag, and tubing dragging on the floor, including in the dining room with no staff intervention. The resident’s room also lacked EBP signage, PPE supplies, and a designated trash can for PPE disposal, and staff gave inconsistent statements about when EBP is required for catheter care.
Three residents in the facility were found with medications left unattended at their bedside without proper assessments for self-administration. One resident, with multiple health conditions, had medications like Biofreeze and cough drops without a care plan. Another resident, with dementia and Parkinson's, had eye drops and nasal spray without physician orders. A third resident, with Parkinson's, had pills and nasal spray left by staff without a documented assessment. The facility's lack of oversight and adherence to medication management policies led to this deficiency.
The facility failed to address grievances and recommendations from the resident council, affecting eight residents and potentially others. Residents were unaware of grievance procedures and did not receive formal feedback. The facility did not document responses to council concerns, and meetings lacked a council president. The Activity Director confirmed the feedback process was informal and untracked.
The facility failed to obtain signatures from two residents or their legal representatives on the NOMNC and SNF ABN forms before discharging them from Medicare services. Despite contacting the residents' durable power of attorney by phone and mail, the necessary signatures were not secured, as required by the form instructions.
The facility failed to maintain privacy for three residents by not posting signage for 24-hour camera surveillance and not obtaining consents. Baby monitors with audio were used without proper consent or signage. Residents involved had cognitive impairments and required assistance with daily activities. The DON stated that signs were unnecessary as cameras were not recording.
The facility failed to include residents' code status wishes in their care plans, affecting five residents. Despite having documented DNR orders, the care plans did not reflect these critical directives. Interviews with staff confirmed the expectation that care plans should address code status, yet this was not implemented.
The facility failed to develop comprehensive care plans for six residents, omitting critical elements such as code status, fall risk interventions, and side rail assessments. Residents experienced multiple falls, and care plans were not updated with new interventions. Staff showed a lack of understanding regarding care plan updates and side rail assessments.
The facility failed to follow professional standards of care, affecting several residents. A resident had side rails installed without a physician's order, while another did not receive prescribed medications consistently. Medications were found at a resident's bedside without orders, and an immobilizer was not worn as required. Additionally, there were blanks in the MAR without annotations. These issues highlight lapses in medication management, safety protocols, and documentation practices.
The facility failed to provide individualized activity programs for two residents, as required by their care plans. One resident, with cognitive impairments and depression, had no documented activity participation despite a goal of two activities daily. Another resident, with Alzheimer's and depression, did not receive preferred activities like pet therapy due to scheduling issues. The Activities Director noted challenges in engaging residents and limited availability of pet therapy.
The facility failed to conduct and document monthly drug regimen reviews for residents, as required by their policies. This affected several residents who were on various medications, including antidepressants and antipsychotics. The facility did not obtain signed statements from the pharmacist when no irregularities were found, and there was no documentation of reviews being completed or provided to physicians.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN did not provide proper instructions for nasal spray administration to a resident, and another resident received an incorrect dosage of eye drops. The LPN was unaware of the lacrimal pressure technique, and the DON confirmed the need to follow manufacturer's guidelines.
The facility failed to ensure food was served at safe and appetizing temperatures, with items held on the steam line for excessive periods without temperature checks. Residents reported dissatisfaction with food quality and temperature, and facility policies lacked guidance on food safety standards.
The facility failed to implement enhanced barrier precautions for two residents with wounds and catheters, lacking necessary signage and PPE. Additionally, clean laundry was transported uncovered, and staff were not adequately trained on infection control measures.
A resident with an indwelling catheter did not receive proper catheter care, as observed in a facility. Staff failed to separate and clean all skin folds and used the same area of a wipe for different areas, contrary to policy. The catheter tubing was also not cleaned. Interviews confirmed the staff's acknowledgment of these errors.
The facility did not follow its medication storage policy by keeping food items like applesauce and Med Pass in the medication refrigerator, which should have been used exclusively for medications. An LPN confirmed the use of these items for medication pass, and the DON stated that such storage was permissible if separated from medications, contrary to the facility's policy.
Improper Hand Hygiene During Kitchen Food Preparation
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety when dietary staff did not use soap and water for handwashing in the kitchen. The facility policy for Food and Nutrition Services, Hand Washing, dated 2025, stated that employees are expected to practice proper hand hygiene and that hands should be washed with soap and water before starting work or handling food, before putting on or changing gloves, and after touching body parts, raw food, garbage, chemicals, dirty dishes, or other contaminated surfaces. During observation of the kitchen, Dietary Aide (A) was seen using hand sanitizer upon entering the kitchen and then beginning food-related tasks without observed handwashing at 9:20 A.M., 12:10 P.M., 12:15 P.M., and 12:25 P.M. Dietary Aide (B) was observed entering the kitchen, using hand sanitizer, and then plating pineapple fruit without handwashing at 12:20 P.M. The Dietary Manager was also observed using hand sanitizer, not washing hands, and then moving boxes, touching kitchen surfaces, and wrapping plates with plastic wrap at 12:32 P.M. In interviews, Dietary Aide (A) stated staff should wash hands with soap and water when entering the kitchen and that hand sanitizer is used when delivering plates to the dining room. The Dietary Manager and Administrator both stated that staff working in the kitchen should use soap and water only and that hand sanitizer is not a substitute for handwashing in the kitchen.
Resident Rights Information Not Accessible or Known to Residents
Penalty
Summary
The facility failed to ensure residents were able to exercise their rights when it did not inform residents where to find contact information for the State Survey Agency, how to file a complaint, or where to find the Ombudsman’s contact information. The deficiency involved one sampled resident, Resident #21, and seven of 14 resident council members. The facility census was 38. Review of the facility’s Residents’ Rights Policy showed that posting names, addresses, and phone numbers of pertinent state client advocacy groups was required, including contact information for the State Survey Agency, the State Long-Term Care Ombudsman program, and the protection and advocacy system. Resident #21’s MDS showed the resident was cognitively intact, used a wheelchair, and could not stand, with diagnoses including chronic respiratory failure, heart failure, and anxiety disorder. During interview, the resident said he/she did not know how to contact the state survey agency or hotline to make a complaint and did not know where the number was located in the building, and also did not know how to contact the ombudsman or where the phone number was located. Observation showed the Ombudsman and DHHS contact information signs were posted about five feet high on the upper left side of a wall in a narrow information area, with direct wheelchair access blocked by a chair, making the signs not viewable to residents in wheelchairs. In a resident council interview, seven of 14 members said they did not know how to file a complaint with the state agency or how to contact it, and seven of 14 did not know where the Ombudsman contact information was located or had not been given written information on how to contact the ombudsman or survey agency. Staff interviews confirmed the numbers were posted high on the wall, that it would be hard for a resident in a wheelchair to see them, and that residents would have to ask staff for the information.
Room Water Temperature and Entrance Threshold Deficiencies
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents whose room bathrooms did not provide hot water at the expected temperature. Resident #26, who had coronary artery disease, heart failure, hypertension, diabetes, and depression, said the bathroom water never got hot and was frustrated that the problem would not be fixed. Observation showed the bathroom hot water reached 96.7 degrees Fahrenheit after running the water for 4 minutes. Resident #28, who was moderately cognitively impaired and had dementia, Parkinson's Disease, and depression, had a family member report that the water in the room had never been hot since the resident moved in, that the issue had been reported to the Administrator, and that hospice staff could not get enough hot water to heat a washcloth for the resident. Additional observations showed multiple room bathrooms on the hall had hot water temperatures below the facility's stated minimum range. Water temperatures measured in several rooms ranged from 96.4 to 103.6 degrees Fahrenheit after running the water for 3 to 5 minutes, and the Maintenance Supervisor measured temperatures of 98.8 degrees Fahrenheit in Resident #28's room and 102.1 degrees Fahrenheit in another room. The Maintenance Supervisor stated the water system pump had been replaced in June 2025, the lines were inspected, and the only report of low temperature he had received was from Resident #28's room. He also stated he knew the state maximum was 120 degrees Fahrenheit but did not know the minimum for residents was 105 degrees Fahrenheit. The facility also failed to ensure safe room access for Resident #2, who had severe cognitive impairment, coronary artery disease, renal insufficiency, obstructive uropathy, Alzheimer's Disease, anxiety disorder, depression, and Schizophrenia, and used a walker and manual wheelchair. Observation showed a raised threshold across the bottom of the room entrance door, and the resident in a wheelchair attempted to cross it 10 times before successfully entering the room. The resident said it would be easier without the threshold, that it was frustrating, and that he/she did not know a complaint could be made. The Maintenance Supervisor said no one had mentioned the threshold problem before and, after seeing it and hearing about the resident's difficulty, was concerned it should be fixed as soon as possible. The Administrator stated a resident should be able to enter the room in a wheelchair without difficulty and that struggling to cross a raised threshold multiple times was not acceptable.
Grievance Process Not Accessible or Consistently Resolved
Penalty
Summary
The facility failed to ensure residents had the right to file grievances in writing, the right to file grievances anonymously, and the right to obtain a written decision regarding grievances. During a resident council group interview, 10 of 14 residents said they did not know how to file a grievance or complaint, did not know where complaint forms were located, did not know how to file an anonymous complaint, and did not know their grievance-related resident rights. Observation showed grievance forms were placed on the back wall of the nurse's station and there was no grievance box in the facility for anonymous submission. Staff interviews showed RN A, the MDS Coordinator, and RN B did not know how residents could file anonymous grievances, and the Administrator said residents could place forms under staff doors. Resident #15 had intact cognitive skills, no behaviors, and diagnoses including fractures, cancer, anxiety, depression, and low back pain. The resident reported that about six months earlier, an LPN yelled and cussed at Resident #16 during care, and Resident #15 filed a grievance with the Administrator. Resident #15 and Resident #16 stated the Administrator said she would explain what would be put in place, but no one followed up with Resident #15. Staff gave conflicting accounts about how the grievance was handled, including that it was turned in to the Administrator and that Social Services would follow up, but the resident reported not receiving the promised follow-up. Resident #28 had moderate cognitive impairment with diagnoses of dementia, Parkinson's disease, and depression. The family member reported complaints about hot water in the room, a medication being stopped without doctor's orders, and medical approvals being signed without the family member's actual agreement or signature. The family member stated these concerns were not responded to with a result of an investigation and no written responses were received from the facility or Administrator. The Administrator later stated the complaints had been addressed and that formal responses were provided, but the family member reported no written decision had been received.
Incomplete Care Plans for Oxygen Use and Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for two residents. The cited policy required care plans to address each resident’s medical, nursing, mental, and psychosocial needs, include measurable objectives and timeframes, and be reviewed and revised by the interdisciplinary team after comprehensive and quarterly MDS assessments. For one resident, the care plan revised 3/6/25 did not address the use of oxygen. The resident’s annual MDS showed intact cognitive skills, no behaviors, partial to moderate assistance needed with oral care and personal hygiene, dependence on staff for toileting, showers, dressing, and transfers, and bowel and bladder incontinence. Diagnoses included COPD, cancer, irregular heartbeat, blood clots, high blood pressure, anxiety, and sepsis. The physician order sheet included an order for oxygen at 1 to 2 liters to keep oxygen saturation above 92% as needed. For the other resident, the care plan revised 9/25/25 addressed behavior related to traumatic brain injury, communication problems, cognition, bowel and bladder status, and ADL function, but did not address inappropriate sexual behaviors. The quarterly MDS showed severely impaired cognitive skills, independence with toileting, dressing, personal hygiene, and transfers, supervision or touch assistance with showers, continence of bowel and bladder, and diagnoses including traumatic brain injury. Staff interviews confirmed that oxygen use and sexual behaviors should have been care planned, and the administrator stated that care plans should be detailed and include specific interventions.
Medication transcription and eye drop administration errors
Penalty
Summary
The facility failed to follow acceptable standards of practice for medication administration for two sampled residents. For one resident with dementia, Parkinson’s disease, and depression, facility staff did not transcribe admission orders correctly after hospital transfers, and Donepezil 10 mg was discontinued by the facility even though hospital discharge orders indicated it should be continued nightly. The record showed the resident went without Donepezil from one date to another, and the resident’s care plan directed staff to administer medications as ordered and monitor for side effects and effectiveness. During interviews, the nurse practitioner stated the resident was intended to remain on Donepezil long term and that sudden discontinuance could cause increased behaviors, non-responsiveness to family members, and lethargy. The nurse practitioner said the resident’s family member reported the medication was not being administered as ordered, which explained the resident’s increased behaviors and lethargy. The family member stated the resident became detached, lethargic, and unresponsive, and that the issue was discovered after reviewing the resident’s medications. The facility also failed to administer eye drops correctly for another resident receiving Betaxolol, Brimonidine, and Dorzolamide for glaucoma. Observation showed the LPN touched the resident’s eyelids and eyelashes with the eye dropper tip while administering the drops, and lacrimal pressure was applied for varying short intervals. The LPN stated the tip should not touch the eyelids or eyelashes and was not sure about the lacrimal pressure. The Administrator also stated the tip should not touch the eyelids or eyelashes and staff should apply lacrimal pressure, but was unaware of the specific time frame.
Respiratory Care Deficiencies With Oxygen Tubing and Humidification
Penalty
Summary
Proper respiratory care was not provided for residents receiving oxygen therapy when staff failed to document when oxygen tubing was cleaned or changed for one resident and failed to provide ordered humidification for three residents. The facility policy stated that oxygen tubing and masks/cannulas were to be changed weekly and as needed, humidifier bottles were to be changed when empty or as recommended by the manufacturer, and delivery devices were to be kept covered in a plastic bag when not in use. The report identified that oxygen tubing was not dated for one resident, and oxygen and nebulizer tubing were not properly stored at the bedside for four residents, leaving the tubing exposed rather than covered as described in the facility policy. One resident with COPD and chronic respiratory failure was observed on oxygen at 7 L/NC, but the oxygen tubing and nebulizer tubing were not dated, and a portable oxygen tank in the bathroom also had tubing that was not dated. Staff interviews confirmed that the tubing should be dated and changed weekly, and that nebulizer canisters should be rinsed, cleaned, dated, and changed weekly. Another resident with chronic respiratory failure, heart failure, and anxiety disorder had an order for oxygen via nasal cannula at 3 liters at rest and 4 to 5 liters with exertion, but during observation the humidifier bottle was not attached to the concentrator and the tubing had no storage bag. Two additional residents with chronic respiratory failure were also observed with oxygen applied and no humidifier bottle attached to the concentrator, and their tubing was not stored in a bag. One of these residents stated the humidifier bottle had been removed because the air did not seem to come out right and reported getting a dry nose and headaches at times. Another resident said the nose gets pretty dry at times and believed there had never been a humidifier bottle on the oxygen concentrator. Staff and management interviews confirmed that humidifier bottles should be present when ordered or care planned, and that oxygen tubing should be dated.
Missing Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to hire or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, despite a census of 38 residents. Survey observations from 12/2/25 through 12/5/25 at various times showed charge nurses were available, but the facility did not have a DON in place. During an interview on 12/2/25 at 10:00 A.M., the Administrator stated that the facility currently did not have a full-time DON, the previous DON stepped down in September or October of that year, there was always an RN scheduled eight hours a day, seven days a week during daytime hours, a licensed nurse was scheduled on every shift, and she had three interviews that week with another scheduled. The facility did not provide a policy for staffing a full-time DON.
Resident Subjected to Verbal Abuse and Refused Care
Penalty
Summary
The facility failed to ensure that one resident was free from verbal abuse when an LPN cursed at the resident and refused to provide care unless the resident changed his/her behavior. The resident had a traumatic brain injury, severe cognitive impairment, and a care plan that addressed behavioral and communication problems, including nighttime care with two staff members present in the room at all times. The resident was also documented as independent with toileting and as continent of bowel and bladder on the MDS, although staff notes and interviews described episodes of incontinence and the need for assistance with cleanup. A progress note documented that another resident reported the abused resident had diarrhea overnight and was still needing to be cleaned up. The note stated that the LPN yelled at the resident and said, if you would quit playing with your genitals, I would help you. The note also stated the resident had dried fecal material on the back, in the bed, on the recliner, and in the groin area, and needed a clean incontinent brief. The resident reported that the LPN did not provide assistance all night and did not get assistance until the next morning. Multiple interviews described similar concerns. A roommate said the resident was yelled at by the night shift nurse and frequently had to try to clean him/herself up, and that the issue had been reported to the Administrator. Another nurse said the evening nurse was very vulgar at times and had heard that the LPN yelled at the resident and said he/she would not take care of him/her if he/she kept touching his/her genitals. The resident stated that a grievance had been given to the Administrator, that the Administrator said she would explain what would be put in place, but did not follow up, and that the LPN was the only staff member who was not nice to him/her. The LPN denied being verbally abusive and denied cursing at the resident.
Failure to Investigate Alleged Verbal Abuse and Withheld Care
Penalty
Summary
The facility failed to implement its abuse policy when it did not conduct a thorough investigation after an allegation of verbal abuse and withheld care was reported involving an LPN and a resident with traumatic brain injury and severe cognitive impairment. The resident’s care plan directed staff to monitor behaviors, anticipate needs, and have two staff members present during nighttime cares. The resident’s MDS showed severe cognitive impairment, independence with basic self-care tasks, and diagnoses including traumatic brain injury. A progress note documented that during morning med pass, a resident reported that the LPN yelled at the resident and said, "if you would quit playing with your [genitals], I would help you." The note also stated the resident had dried fecal material on the back, in the bed, on the recliner, and in the peri area, and needed a clean incontinent brief. The note further stated the LPN did not provide assistance all night and did not get assistance until the next morning. Another resident later reported hearing the LPN yell and cuss at the resident and say the resident was not going to get help if the resident kept playing with his/her genitals. Interviews showed the allegation was reported to multiple staff, including RN A, the Social Services Designee, the Administrator, and others, but the grievance was not handled as an abuse allegation. The Social Services Designee said no grievances had been filed since 2/28/25 and was unaware of the grievance about verbal abuse and refusal to provide care. RN B stated he/she did not document the conversation, complete a grievance, or notify Social Services or the Administrator, although he/she said he/she should have. The Administrator stated that reporting to the charge nurse was considered sufficient, that the resident did not need to fill out a grievance, and that the staff member involved should have been suspended until an investigation was completed. The Administrator also stated the facility had not addressed the resident’s behaviors or implemented ways to help the resident, and that the only investigations done in the prior three months were not related to patient care or abuse.
Incomplete Perineal Care for Dependent Residents
Penalty
Summary
The facility failed to ensure dependent residents received complete perineal care when staff did not clean all areas of the skin that had been touched by urine or feces for two residents who were unable to perform ADLs independently. The facility policy dated 5/2/25 stated that incontinent residents were to receive perineal care to promote cleanliness and comfort, prevent infection to the extent possible, and prevent and assess for skin breakdown, including cleansing all genital areas from front to back and using a clean portion of the washcloth or wipe with each stroke. One resident was totally dependent on two staff for toileting, was incontinent of bowel and bladder, and had diagnoses including COPD, cancer, irregular heartbeat, blood clots, high blood pressure, anxiety, and sepsis. During observation, CNA E and NA A transferred the resident to bed, removed wet clothing and an incontinent brief, and wiped the groin and perineal area, but did not separate and clean all perineal folds or all areas of skin where urine or feces had touched. Another resident was cognitively intact but dependent on staff for toileting, hygiene, and transfers, with diagnoses including hemiplegia, high blood pressure, and diabetes. During observation, CNA D and CNA E assisted the resident to the toilet and provided peri care, but CNA E did not separate and clean all areas of the skin where urine had touched. Staff interviews confirmed that peri care should include cleaning all areas of the genital area and all areas of skin that were wet or soiled.
Failure to Address Resident Sexual Behaviors in Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a traumatic brain injury and severe cognitive impairment who had repeated sexually inappropriate behaviors. The resident’s care plan identified a behavior problem related to the brain injury and directed staff to discuss inappropriate behavior, monitor episodes, and report behaviors to the charge nurse, but it did not include specific interventions for sexual behaviors or alternative ways for the resident to deal with them. The resident’s quarterly MDS showed severe cognitive impairment, independence with toileting and personal care, and diagnoses including traumatic brain injury. Progress notes documented multiple incidents in which the resident exposed or fondled his genitals in front of staff, including while walking out of the bathroom, standing in the bathroom doorway, and during medication delivery. One note also described the resident being assisted after an episode of diarrhea, with dried fecal material on his back, in his bed, and in his recliner, and staff documented that the resident completed his own shower and dressing. Staff interviews described repeated sexually inappropriate behavior and indicated that some staff responded by telling the resident to stop or by leaving the room, while other staff reported discomfort and said the behavior was frequently reported to the nurse or administrator. Interviews also showed that staff did not consistently provide care when the resident was incontinent or needed shower assistance. RN, LPN, CNA, and resident interviews described staff refusing or delaying care, making comments about not helping until the resident stopped touching himself, and saying that staff did not like to take care of him. Social services and the administrator stated that the resident had been on behavioral services and refused them, that the care plan should address the resident’s behaviors with specific interventions, and that the facility had not addressed the behaviors in the care plan with interventions or sought outside resources.
Incorrect PBJ Staffing Submission
Penalty
Summary
The facility failed to submit Payroll Based Journal (PBJ) direct care staffing information correctly for Quarter 3, 2025, based on payroll and other verifiable and auditable data. Review of the facility’s PBJ Staffing Data Report showed that licensed nursing coverage was reported as not being present 24 hours per day on 4/2/25, 4/12/25, 4/15/25, and 6/6/25, even though review of the daily staffing sheets showed the facility did have licensed nursing coverage 24 hours per day on those dates. The facility census was 38, and the facility did not have a policy for reporting direct care staffing information. During interview, the Administrator stated the facility always had a licensed nurse on duty for eight hours on every shift and that staffing information was entered by the corporate office, but it should have been filled out correctly.
Failure to Use EBP and Maintain Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to ensure staff provided care in a manner to prevent infection when a resident with an indwelling urinary catheter did not have enhanced barrier precautions (EBP) properly set up and when the resident’s catheter tubing and dignity bag were observed dragging on the ground while the resident was in a wheelchair. The resident was cognitively intact and had diagnoses including cancer, atrial fibrillation, neurogenic bladder, depression, and a thyroid disorder. The resident’s care plan identified the indwelling catheter and stated the resident would show no signs of urinary infection, and the order summary included catheter-related orders, but there were no orders for EBP for the resident. Observations showed the resident in a wheelchair with the catheter bag and tubing dragging on the floor underneath the wheelchair, including in the dining room with no staff intervention. When the resident’s room was observed, there was no EBP sign at the entrance, no gloves or extra PPE available, and no trash can designated for PPE disposal after care. Staff interviews reflected inconsistent understanding of EBP, with some stating it was for C-diff, viral contagious situations, or airborne precautions, while others said it was not required for a resident with a catheter. The Administrator stated staff should use EBP when performing direct cares on residents with catheters and acknowledged the catheter dignity bag and tubing should not be dragging on the ground.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that three residents were assessed for the safety of self-administering medications, leading to medications being left unattended at their bedside. Resident #6, who was cognitively intact and had multiple diagnoses including high blood pressure and diabetes, had medications such as Biofreeze, cough drops, and vapor rub at their bedside without a proper assessment or care plan for self-administration. The resident stated they did not self-administer medications, yet used Biofreeze for pain relief, indicating a lack of oversight and adherence to the facility's policy. Resident #34, also cognitively intact but with conditions such as dementia and Parkinson's disease, had various medications including eye drops and nasal spray at their bedside without any physician orders or assessments for self-administration. Interviews with the Director of Nursing and an LPN revealed a lack of awareness and documentation regarding residents' ability to self-administer medications, highlighting a systemic issue in the facility's medication management practices. Resident #31, who had no cognitive deficits and was diagnosed with Parkinson's disease, had medications left at their bedside, including a medicine cup with pills and nasal spray, without a documented assessment or care plan for self-administration. The resident indicated that staff left the medications for them to take, and the Director of Nursing confirmed the lack of completed assessments for self-administration. This oversight in medication management and assessment procedures contributed to the deficiency identified by the surveyors.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not considering the views of the resident council and not acting promptly upon grievances and recommendations made by the group. The facility did not demonstrate their response or provide a rationale for such responses to the grievances and recommendations. Additionally, the facility failed to maintain documentation of attempts to resolve concerns or communicate follow-up actions to the council. This affected all eight residents serving on the resident council and potentially other residents in the facility, which had a census of 37. During interviews, residents reported not having access to grievance forms or knowledge of the Council Response Form for receiving feedback on grievances. They were also unaware of who the Grievance Officer was and did not receive formal feedback on their grievances. The review of resident council minutes from June to August 2024 showed no facility responses to past complaints or requests, and meetings were led by the Activity Director without a council president. The Activity Director confirmed that the facility did not formally reply to the resident council on resolutions or steps taken to address issues, and the feedback process was informal and not tracked.
Failure to Obtain Required Signatures on Medicare Notices
Penalty
Summary
The facility failed to obtain signatures from residents or their legal representatives on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms before discharging two residents from Medicare services. This deficiency was identified for two out of three sampled residents, with the facility census being 37. The NOMNC and SNF ABN forms require a signature from the beneficiary or their authorized representative to acknowledge that they have read and understood the notice. The facility did not secure these signatures for Resident #23 and Resident #13, despite making phone calls and sending letters to their durable power of attorney. For Resident #23, the facility documented a phone call and mailed a letter to the resident's durable power of attorney on the same day, two days before the resident was discharged from skilled Medicare services. Similarly, for Resident #13, the facility documented a phone call and mailed a letter to the resident's durable power of attorney five days before the discharge. However, in both cases, the facility did not obtain the necessary signatures on the NOMNC and SNF ABN forms, as required by the form instructions. During an interview, the Administrator acknowledged the expectation that beneficiary notices should be signed by the responsible party.
Privacy Breach Due to Unconsented Camera Surveillance
Penalty
Summary
The facility failed to maintain the privacy of three residents by not posting signage indicating 24-hour camera surveillance and not obtaining consents from responsible parties. The facility's policy on videotaping and photographing residents did not address the use of camera surveillance or the need for consents. Observations revealed that baby monitors with audio capabilities were used in residents' rooms without proper signage or consent. Resident #10 had a care plan indicating a camera was in the room to monitor for falls, but there was no consent for 24-hour surveillance. The resident had cognitive impairment and required assistance with daily activities. A baby monitor was observed in the room, and a monitor at the nurse's station displayed the resident's room with audio capabilities. Resident #32's care plan did not address the roommate's camera surveillance, and there was no consent from the responsible party. The resident had severe cognitive impairment and required assistance with daily activities. Similarly, Resident #17's care plan did not indicate surveillance, and there was no consent for video monitoring. The resident was severely cognitively impaired and dependent on staff for care. The Director of Nursing stated that no signs were needed as the cameras were not recording, and the family had requested them.
Failure to Address Code Status in Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for five residents, specifically neglecting to address their code status wishes. This deficiency was identified through observation, interviews, and record reviews. The facility's policy mandates that care plans should include measurable objectives and timetables to meet residents' needs, developed by an interdisciplinary team in conjunction with the resident and their family or legal representative. However, the care plans for five residents did not reflect their expressed wishes regarding do not resuscitate (DNR) orders, despite these being documented in the facility's code status book and physician's orders. For instance, Resident #18 had a signed out-of-hospital DNR sheet, but their care plan did not address this code status. Similarly, Resident #34 and Resident #6 had DNR orders documented, but their care plans failed to include this critical information. Interviews with facility staff, including an LPN and the MDS Coordinator, confirmed that care plans should address residents' code status. The Administrator acknowledged that care plans should be updated with significant changes and that code status is reviewed at every care plan meeting, yet the deficiency persisted.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for six residents, which did not align with the residents' medical, nursing, mental, and psychosocial needs. For Resident #7, the care plan did not include the resident's code status wishes, despite having a DNR order. Similarly, Resident #27's care plan omitted the code status and did not address the resident's high risk for falls, even though the resident had a history of falls and a high fall risk score. Resident #17's care plan lacked interventions for the 24-hour video and audio surveillance in the resident's room, which was observed at the nurse's station. Resident #6's care plan did not address the use of side rails, despite the resident using them for assistance at night. The assessments showed inconsistencies in the indication for side rails, with the resident expressing a desire for them to promote independence. Resident #18's care plan did not include any assessments for side rails, although they were observed in use. Resident #34's care plan did not include new fall interventions after multiple falls, and side rails were not care planned despite being used to hold the call light. The facility's staff, including the DON and LPN, demonstrated a lack of understanding regarding the necessity of updating care plans with significant changes and the inclusion of side rail assessments.
Deficiencies in Medication Management and Resident Safety Protocols
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, affecting multiple residents. For Resident #18, side rails were installed without a physician's order, despite the previous discontinuation of such an order. Observations confirmed the presence of side rails, and the Director of Nursing was unaware of the requirement for physician orders for bed rails. This oversight indicates a lack of compliance with established protocols for resident safety and care. Resident #31 did not receive prescribed medications consistently, with Pataday Ophthalmic Solution not administered for 27 days and Polyethylene Glycol given only 12 times out of 27 days. The resident reported not receiving eye drops for months, and staff confirmed the medication was out of stock without being reordered. This failure to provide necessary medication as per physician orders highlights a significant lapse in medication management and inventory control. For Resident #34, there was no assessment for self-administration of medications, yet multiple medications were found at the bedside without orders. Additionally, the resident was observed without an immobilizer, contrary to physician orders. The facility's documentation practices were also deficient, as evidenced by blanks in the Medication Administration Record (MAR) for Resident #6, with no annotations explaining the omissions. These deficiencies collectively demonstrate a failure to maintain accurate records and ensure adherence to prescribed care plans.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that supports residents in their choice of activities, affecting two residents out of a sample of 12. The facility's policies require activities to be scheduled seven days a week and tailored to individual needs, with records maintained for attendance and participation. However, the facility did not document any activities for Residents #12 and #29 over the last 90 days, indicating a lack of adherence to these policies. Resident #12, with moderately impaired cognitive skills and multiple health conditions including depression, had no documented activity participation despite a care plan goal of engaging in two activities daily. The resident's care plan included encouragement to participate in group activities and independent activities like reading mail and sitting outside. However, there was no evidence of these activities being offered or documented, and the Activities Director noted difficulty in engaging the resident due to frequent sleeping. Resident #29, with severely impaired cognitive skills and several health conditions including Alzheimer's and depression, also had no documented activity participation. The resident's care plan emphasized the importance of pet therapy and family visits, yet these preferences were not met, with pet therapy occurring infrequently due to scheduling issues. The Activities Director acknowledged the limited availability of pet therapy and could not recall the last session, highlighting a gap in meeting the resident's individual activity preferences.
Failure to Conduct and Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for residents, as required by their policies and procedures. Specifically, the facility did not obtain a signed and dated statement from the pharmacist when no irregularities were identified during the medication regimen review. Additionally, the pharmacist's date of review and name were not listed on any medication regimen reviews. This deficiency affected five of the twelve sampled residents, and there was no documentation that a monthly medication regimen review was completed or provided to the physician. For Resident #6, the facility's records showed that there were no drug regimen reviews conducted from April to July 2024. The resident was on several medications, including an antidepressant, anticoagulant, and diuretic, and had a history of high blood pressure, heart failure, diabetes, depression, asthma, neuropathy, and generalized muscle weakness. Despite the absence of documented reviews, progress notes indicated that pharmacy consults were received with no irregularities noted in previous months. Similarly, for Resident #18, there were no documented drug regimen reviews from April to July 2024. The resident was on antipsychotic, anticoagulant, and diuretic medications, with diagnoses including dementia, anxiety disorder, and depression. The facility's records showed that gradual dose reductions were attempted, but there was no documentation of the pharmacist's review or physician's acknowledgment. The lack of proper documentation and communication between the pharmacist and the physician contributed to the facility's failure to comply with its medication regimen review policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8% due to two medication errors out of 25 opportunities. This affected two residents. One resident was observed self-administering Flonase nasal spray without proper instructions from the LPN, who did not instruct the resident to close one side of the nostril as per the manufacturer's guidelines. The LPN admitted to not providing instructions and only following the physician's orders, while the Director of Nursing acknowledged that staff should follow the manufacturer's guidelines unless otherwise directed. Another resident received an incorrect dosage of Systane eye drops, with the LPN administering two drops in each eye instead of the ordered one drop. Additionally, the LPN did not apply lacrimal pressure, a technique not known to the LPN or the Director of Nursing. The Director of Nursing confirmed that staff should administer the correct amount of eye drops as ordered and was unaware of the lacrimal pressure technique.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations revealed that cooked foods were not temperature checked and were held on the steam line for excessive periods, with spinach and au gratin potatoes warming for three hours and the main course ham for two hours. No temperatures were taken for any items on the steam line before or during serving, and banana pudding was served without temperature checks to ensure it was below 41 degrees. Interviews with residents indicated dissatisfaction with the food quality and temperature. One resident, who was cognitively intact, reported that while food temperatures were appropriate, the taste was unsatisfactory. Another resident with significant cognitive impairment mentioned that food was sometimes cold, and vegetables were inconsistently cooked. A resident's responsible party also noted that the food was often cold and unpalatable. The facility's policies lacked guidance on food safety standards, and there was no policy on required temperature checks of cooked food. The Dietary Manager and Administrator both expressed expectations that food should not be on the steam line for more than two hours and that temperature checks should be conducted according to facility policy. However, these expectations were not met, leading to the deficiency in food service quality.
Inadequate Infection Control Measures for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of enhanced barrier precautions (EBP) for residents with open wounds and catheters. Resident #18, who had a stage 3 pressure ulcer and was dependent on a wheelchair for mobility, did not have EBP signage or personal protective equipment (PPE) in or outside their room. Despite having a care plan that required specific wound care, observations over several days confirmed the absence of necessary precautions. Similarly, Resident #17, who was severely cognitively impaired and had an indwelling urinary catheter, also lacked EBP signage and PPE. The resident required substantial assistance for daily activities and had multiple diagnoses, including cancer and dementia. Observations during room visits confirmed that no enhanced barrier precautions were in place for this resident. Additionally, the facility did not have a policy for the transportation of clean laundry, leading to uncovered laundry being transported throughout the facility. Interviews with staff, including the Laundry Aide and LPN, revealed a lack of understanding and training regarding EBP. The Infection Preventionist and Administrator acknowledged the absence of precautions and signage, citing issues with ordering and implementing necessary materials.
Improper Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide proper catheter care to prevent urinary tract infections for a resident with an indwelling catheter. The resident, who had obstructive uropathy and was dependent on staff for all toileting needs, was observed receiving inadequate catheter care. During the care, a Certified Nurse Aide (CNA) and a Nurse Aide (NA) did not separate and clean all areas of the resident's skin folds properly and used the same area of a wipe to clean different areas, which is against the facility's policy. Additionally, the catheter tubing was not cleaned during the process. Interviews with the involved staff confirmed the improper cleaning techniques used during the catheter care. Both the CNA and NA acknowledged that they should have separated and cleaned all skin folds and used a different area of the wipe for each area of the skin. They also admitted that the catheter tubing should have been cleaned. The Director of Nursing reiterated that the staff should follow the correct procedure of one wipe, one swipe, and ensure all skin folds and catheter tubing are cleaned properly.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its medication storage policy by storing food items alongside medications in the medication refrigerator. During an observation and interview, it was noted that the refrigerator contained at least 15 containers of applesauce, nine containers of Med Pass (an oral nutritional supplement), and two small containers of tomato juice, which were reportedly used for medication pass. The facility's policy mandates that medications requiring refrigeration must be stored separately from food and labeled accordingly. However, the Director of Nursing indicated that these food items could be stored in the refrigerator as long as they were separated from the medication, which contradicts the facility's policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mound City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oregon Care Center | 12.1 mi | ★★★★★ | 9 | 0 |
| Falls City Nursing And Rehabilitation Center | 19.7 mi | ★★★★★ | 1 | 0 |
| Nodaway Healthcare | 20 mi | ★★★★★ | 2 | 0 |
| Falls City Care Center | 20.4 mi | ★★★★★ | 0 | 0 |
| Parkdale Manor Health & Rehabilitation | 22.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.